Healthcare Provider Details

I. General information

NPI: 1417486325
Provider Name (Legal Business Name): NORTHERN KENTUCKY BEHAVIORAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 DOLWICK DRIVE
ERLANGER KY
41018
US

IV. Provider business mailing address

PO BOX 4394
BRICK NJ
08723-0016
US

V. Phone/Fax

Practice location:
  • Phone: 732-747-1800
  • Fax:
Mailing address:
  • Phone: 732-747-1800
  • Fax: 732-747-1818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TOM ROURKE
Title or Position: SENIOR VP FOR DEVELOPMENT
Credential:
Phone: 972-467-4461